How To Use CPT Code 53215

CPT 53215 describes the complete removal of the urethra and the creation of an opening from the urinary bladder to the skin for drainage of urine in male patients. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 53215?

CPT 53215 is used to describe the surgical procedure in which the provider removes the entire urethra in male patients and creates an opening from the urinary bladder to the skin for urine drainage. This procedure is typically performed to treat extensive tumors of the urethra.

2. Official Description

The official description of CPT code 53215 is: ‘Urethrectomy, total, including cystostomy; male.’

3. Procedure

1. The provider makes a small incision in the suprapubic area below the bladder to access the urethra.
2. The incision is extended to the level of fascia and muscle.
3. The provider dissects out the urethra.
4. The urethral opening into the bladder is clipped and dissected from the bladder.
5. The entire urethra is excised.
6. The urethral opening into the bladder is closed.
7. The provider makes a small opening in the bladder and another in the skin.
8. The bladder opening is sutured to the skin to allow for urine drainage.
9. Any bleeding is controlled, and the incision is closed in layers using absorbable sutures.

4. Qualifying circumstances

CPT 53215 is performed on male patients who require the complete removal of the urethra and the creation of a cystostomy for urine drainage. This procedure is typically done to treat extensive tumors of the urethra.

5. When to use CPT code 53215

CPT code 53215 should be used when a provider performs a total urethrectomy with cystostomy in male patients. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 53215, the provider must document the following information:

• Patient’s diagnosis necessitating the urethrectomy
• Details of the procedure, including the incision, dissection, excision, and closure
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 53215, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document and code the procedure to avoid claim denials or incorrect reimbursement. Modifier 52, Reduced services, may be used if the patient previously underwent radical cystectomy and presents for a total urethrectomy.

8. Historical information

CPT 53215 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient with an extensive urethral tumor undergoes a total urethrectomy with cystostomy to ensure complete removal of the affected tissue.
2. A male patient with recurrent urethral cancer requires a total urethrectomy with cystostomy for urine drainage.
3. A provider performs a total urethrectomy with cystostomy on a male patient with a severe urethral stricture that cannot be managed with less invasive treatments.
4. A patient with a large urethral diverticulum undergoes a total urethrectomy with cystostomy to alleviate symptoms and prevent complications.
5. A male patient with extensive trauma to the urethra requires a total urethrectomy with cystostomy for urinary diversion.
6. A provider performs a total urethrectomy with cystostomy on a male patient with a recurrent urinary tract infection caused by a persistent urethral stricture.
7. A patient with a malignant urethral tumor undergoes a total urethrectomy with cystostomy as part of their cancer treatment plan.
8. A male patient with a congenital urethral abnormality requires a total urethrectomy with cystostomy to improve urinary function and prevent complications.
9. A provider performs a total urethrectomy with cystostomy on a male patient with a history of recurrent urethral strictures that have not responded to previous treatments.
10. A patient with a large urethral calculus undergoes a total urethrectomy with cystostomy to remove the stone and prevent further complications.